ASSESSMENT AND DIAGNOSIS Overview Importance of Pain Assessment

ASSESSMENT AND DIAGNOSIS

Overview

Importance of Pain Assessment Pain is a significant predictor of morbidity and mortality. • Screen for red flags requiring immediate investigation and/or referral • Identify underlying cause – Pain is better managed if the underlying causes are determined and addressed • Recognize type of pain to help guide selection of appropriate therapies for treatment of pain • Determine baseline pain intensity to future enable assessment of efficacy of treatment Forde G, Stanos S. J Fam Pract 2007; 56(8 Suppl Hot Topics): S 21 -30; Sokka T, Pincus T. Poster presentation at ACR 2005.

Comprehensive Pain Assessment Assess effects of pain on patient’s function Characterize pain location, distribution, duration, frequency, quality, precipitants Complete risk assessment Take detailed history (e. g. , comorbidities, prior treatment) Clarify etiology, pathophysiology Conduct physical examination National Pharmaceutical Council, Joint Commission on Accreditation of Healthcare Organizations. Pain: Current Understanding of Assessment, Management, and Treatments. Reston, VA: 2001; Passik SD, Kirsh KL CNS Drug 2004; 18(1): 13 -25.

Assessment of Acute Pain • Site of pain • Circumstances associated with pain onset • Character of pain • Intensity of pain • Associated symptoms (e. g. , nausea) • Comorbidities • Treatment – Current and previous medications, including dose, frequency of use, efficacy and side effects • Relevant medical history – Prior or coexisting pain conditions and treatment outcomes – Prior or coexisting medical conditions • Factors influencing symptomatic treatment Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence. 3 rd ed. ANZCA & FPM; Melbourne, VIC: 2010.

Acute Pain Evaluation and Treatment Patient presenting with acute pain Perform diagnostic evaluation Perform assessments Yes Pain is severe/disabling: requires opioids No Treat appropriately Re-evaluate and adjust treatment if indicated Ayad AE et al. J Int Med Res 2011; 39(4): 1123 -41. Refer to specialist

History

Clinical Assessment of Pain Functional Assessment Does the pain interfere with activities? Psychological Assessment Does the patient have concomitant depression, anxiety, or mental status changes? Does the patient have sleep disorders or a history of substance abuse/dependence? Medication History What medications have been tried in the past? Which medications have helped? Which medications have not helped? Wood S. Assessment of pain. Nursing Times. net 2008. Available at: http: //www. nursingtimes. net/nursing-practice/clinical-zones/pain-management/assessment-ofpain/1861174. article. Accessed: October 7, 2013.

Pain History Worksheet • • • Site of pain What causes or worsens the pain? Intensity and character of pain Associated symptoms? Pain-related impairment in functioning? Relevant medical history Ayad AE et al. J Int Med Res 2011; 39(4): 1123 -41.

Pain Assessment: PQRST Mnemonic • • • Provocative and Palliative factors Quality Region and Radiation Severity Timing, Treatment Budassi Sheehy S, Miller Barber J (eds). Emergency Nursing: Principles and Practice. 3 rd ed. Mosby; St. Louis, MO: 1992.

Assessing Acute Pain Intensity • Visual analog scale (VAS) – Self-rating on a 0– 100 mm scale • Numerical rating scale – Self-rating on a 11 -point scale: 0 = no pain to 10 = worst pain • Time-specific pain intensity – “My pain at this time is: none, mild, moderate, severe” (0 to 3 rating) Impact of Pain on Function • American Pain Society (APS) questionnaire – The degree to which pain interferes with patient function, such as mood, walking and sleep • Brief Pain Inventory (BPI) – Evaluates severity, impact and impairment on daily living, mood and enjoyment of life • Time-specific pain relief – “My pain relief at this time is: none, a little, some, a lot, complete” (0 to 4 rating) Coll AM et al. J Adv Nursing 2004; 46(2): 124 -133; Dihle A et al. J Pain 2006; 7(4): 272 -80; Keller S et al. Clin J Pain 2004; 20(5): 309 -18.

Locate the Pain Body maps are useful for the precise location of pain symptoms and sensory signs. * *In cases of referred pain, the location of the pain and of the injury or nerve lesion/dysfunction may not be correlated Gilron I et al. CMAJ 2006; 175(3): 265 -75; Walk D et al. Clin J Pain 2009; 25(7): 632 -40.

Determine Pain Intensity Simple Descriptive Pain Intensity Scale Mild pain No pain Moderate pain Severe pain Worst pain Very severe pain 0– 10 Numeric Pain Intensity Scale 0 No pain 1 2 3 4 5 Moderate pain 6 7 Faces Pain Scale – Revised International Association for the Study of Pain. Faces Pain Scale – Revised. Available at: http: //www. iasppain. org/Content/Navigation. Menu/General. Resource. Links/Faces. Pain. Scale. Revised/default. htm. Accessed: July 15, 2013; Iverson RE et al. Plast Reconstr Surg 2006; 118(4): 1060 -9. 8 9 10 Worst possible pain

APS Questionnaire • Measures 6 aspects of quality: – Pain severity and relief – Impact of pain on activity, sleep and negative emotions – Side effects of treatment – Helpfulness of information about pain treatment – Ability to participate in pain treatment decisions – Use of non-pharmacological strategies Gordon DB et al. J Pain 2010; 11(11): 1172 -86.

Brief Pain Inventory Cleeland CS, Ryan KM. Ann Acad Med Singapore 1994; 23(2): 129 -38.

Mc. Gill Pain Questionnaire Melzack R. Pain 1975; 1(3): 277 -99.

Physical Examination

Acute Neck Pain: Physical Examination • Physical examination does not provide a patho-anatomic diagnosis of acute idiopathic or whiplash-associated neck pain as clinical tests have poor reliability and lack validity • Despite limitations, physical examination is an opportunity to identify features of potentially serious conditions • Tenderness and restricted cervical range of movement correlate well with the presence of neck pain, confirming a local cause for the pain Ariens GAM et al. In: Crombie IK (ed). Epidemiology of Pain. IASP Press; Seattle, WA: 1999; Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Acute Shoulder Pain: Physical Examination • • • Inspection Palpation Range of motion as compared to unaffected side Strength assessment Provocative shoulder testing for possible impingement syndrome and glenohumeral instability Findings of shoulder examination must be interpreted cautiously in light of evidence of limited utility. However, physical examination is an opportunity to identify features of potentially serious conditions. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004; Woodward TW, Best TM. Am Fam Physician 2000; 61(10): 3079 -88.

Shoulder Evaluation Tests Test Maneuver Patient touches superior Apley scratch test and inferior aspects of opposite scapula Diagnosis suggested by positive result Loss of range of motion: rotator cuff problem Neer's sign Arm in full flexion Hawkins' test Forward flexion of the shoulder Supraspinatus tendon to 90 degrees and impingement internal rotation Drop-arm test Arm lowered slowly to waist Cross-arm test Forward elevation to 90 degrees Acromioclavicular joint arthritis and active adduction Spurling's test Spine extended with head rotated to affected shoulder while axially loaded Woodward TW et al. Am Fam Physician 2000; 61(10): 3079 -88. Subacromial impingement Rotator cuff tear Cervical nerve root disorder

Shoulder Evaluation Tests (cont’d) Diagnosis suggested by positive result Test Apprehension test Maneuver Anterior pressure on the humerus with external rotation Relocation test Posterior force on humerus Anterior glenohumeral instability while externally rotating the arm Sulcus sign Pulling downward on elbow or wrist Yergason test Elbow flexed to 90 degrees with Biceps tendon instability forearm pronated or tendonitis Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated Biceps tendon instability or tendonitis “Clunk” sign Rotation of loaded shoulder from extension to forward flexion Labral disorder Woodward TW, Best TM. Am Fam Physician 2000; 61(10): 3079 -88. Anterior glenohumeral instability Inferior glenohumeral instability

Sensitivity and Specificity of Maneuvers Assessing Rotator Cuff Integrity Supraspinatus Jobe (empty can) Sensitivity Specificity Full can 44%¹ 90%¹ EMG *Partial rupture; †Full rupture EMG = electromyogram X Infraspinatus Subscapularis Infraspinatus 45° internal rotation Lift-off 42%* 100%† 18%* 60%* 90%* 100%† 100%* 92%* X Bergeron Y et al. Pathologie médicale de l’appareil locomoteur. 2 nd ed. Edisem Inc; St. Hyacinthe, QC: 2008; Barth JR et al. Arthroscopy 2006; 22(10): 1076 -84. Lift-off push X Bear hug

Acute Knee Pain: Physical Examination • Compare painful and asymptomatic knees • Palpate • Check for pain, warmth, effusion and point tenderness • Assess range of motion • Perform physical maneuvers Although examination techniques lack specificity for diagnosing knee disorders, physical examination may assist the identification of serious conditions underlying pain. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004; Ebell MJ. Am Fam Physician 2005; 71(6): 1169 -72.

Accuracy of Physical Exam Maneuvers for Diagnosis of Knee Injury Positive LR* Negative LR* Probability of specific injury if examination maneuver is: † Positive (%) Negative (%) 12. 4 0. 14 58 2 3. 7 0. 6 29 6 20. 3 0. 4 69 4 1. 1 0. 8 11 8 17. 3 0. 5 66 5 Maneuver ACL tears Lachman test Anterior drawer test Pivot test Meniscal injury Joint line tenderness Mc. Murray test *The likelihood ratio is a measure of how well a positive test rules in disease or a negative test rules out disease †Given an overall likelihood of each injury of 10%; if clinical suspicion is higher or lower than this 10% pretest probability, then the probability would be correspondingly higher or lower Jackson JL et al. Ann Intern Med 2003; 139(7): 575 -88.

Imaging and Other Tests

Investigations for Potential Serious Causes of Acute Neck Pain Suspected condition CRP ESR FBC IEPG MRA MRI PSA Serum protein electrophoresis Fracture X Infection All cases X X X Spinal X Tumor All cases Myeloma 1 st line 2 nd line X X Prostate Aneurysm X-ray X X CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; FBC = full blood count; IEPG = immuno-electrophoretogram; MRA = magnetic resonance angiography; MRI = magnetic resonance imaging; PSA = prostate-specific antigen Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Canadian C-Spine Rule Any high-risk factor that mandates radiography? • Age > 65 years, or • Dangerous mechanism of injury, or • Paraesthesias in extremities No • • • Any low-risk factor that allows safe assessment of range of motion? Simple rear-end motor vehicle collision, or Sitting position in emergency department, or Ambulatory at any time, or Delayed onset of neck pain (i. e. , not immediate), or Absence of midline cervical spine tenderness Yes Able to actively rotate neck 45° left and right? Stiell IG et al. JAMA 2001; 286(15): 1841 -8. No Radiography No Yes No radiography

Acute Neck Pain: When to Order CT • X-ray results: – Positive – Suspicious – Inadequate – Suggest injury at the occiput to C 2 levels • Neurological signs or symptoms are present • Severe head injury • Severe injury with signs of lower cranial nerve injury or pain and tenderness in the sub-occipital region CT = computed tomography Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Investigations for Potential Serious Causes of Acute Shoulder or Knee Pain Suspected condition Aspiration/ microscopy CRP ESR FBC IEPG MRI Serum protein electrophoresis Fracture X Infection All cases X X X Osteomyelitis Joint X X Tumor 1 st line All cases 1 st line Myeloma Crystal arthritis X-ray 2 nd line X X X Osteonecrosis CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; FBC = full blood count; IEPG = immuno-electrophoretogram; MRI = magnetic resonance imaging X Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Knee Pain: When to X-ray Bauer Rule • Inability to bear weight AND • Presence of an effusion or an ecchymosis Ottawa ANY ≥ 1 of: • Age ≥ 55 • Isolated tenderness of patella • Tenderness at head of fibula • Inability to flex to 90 o • Inability to bear weight Pittsburgh • History of fall or blunt trauma AND ≥ 1 of: • Age <12 • Age >50 • Cannot walk 4 weight-bearing steps Sensitivity 100% 97% 99% Specificity 100% 27% 60% Likelihood ratio - 1. 3% 2. 5 Bauer SJ et al. J Emerg Med 1995; 13(5): 611 -5; Seaberg DC et al. Am J Emerg Med 1994; 12(5): 541 -3; Stiell IG et al. JAMA 1996; 275(8): 611 -5.

Knee Pain: When to Order CT and Ultrasound CT • Suspected fracture and normal X-ray results CT = computed tomography Ultrasound • Swelling or potential rupture of anterior knee structures Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Diagnosis

Differential Diagnosis of Knee Pain • • Anterior knee pain Patellar subluxation or dislocation Tibial apophysitis (Osgood-Schlatter lesion) Jumper's knee (patellar tendonitis) Patellofemoral pain syndrome (chondromalacia patellae) Lateral knee pain • Lateral collateral ligament sprain • Lateral meniscal tear • Iliotibial band tendonitis Posterior knee pain • Popliteal cyst (Baker's cyst) • Posterior cruciate ligament injury Calmbach WL et al. Am Fam Physician 2003; 68(5): 917 -22. • • Medial knee pain Medial collateral ligament sprain Medial meniscal tear Pes anserine bursitis Medial plica syndrome

Diagnosis of Shoulder Pain Key Findings in the History and Physical Examination Finding Probable diagnosis Scapular winging, trauma, recent viral Serratus anterior or trapezius dysfunction illness Seizure and inability to passively or actively Posterior shoulder dislocation rotate affected arm externally Supraspinatus/infraspinatus wasting Pain radiating below elbow; decreased cervical range of motion Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement Pain or “clunking” sound with overhead motion Nighttime shoulder pain Generalized ligamentous laxity Woodward TW et al. Am Fam Physician 2000; 61(10): 3079 -88. Rotator cuff tear; suprascapular nerve entrapment Cervical disc disease Glenohumeral joint instability Labral disorder Impingement Multidirectional instability

Look for Red Flags for Musculoskeletal Pain • Older age with new symptom onset • Night pain • Fever Littlejohn GO. R Coll Physicians Edinb 2005; 35(4): 340 -4. • Sweating • Neurological features • Previous history of malignancy

Acute Neck, Shoulder and Knee Pain: Red Flags Feature or risk factor Condition • Symptoms and signs of infection • Risk factors for infection • Signs of inflammation in knee Infection • History of trauma • Use of corticosteroids with neck or knee pain • Sudden onset of pain in shoulder Fracture, shoulder dislocation, tendon and ligament rupture or osteonecrosis in knee • • Past history of malignancy Age >50 years Failure to improve with treatment Unexplained weight loss Dysphagia, headache, vomiting with neck pain Pain at multiple sites Shoulder or knee pain at rest Night pain in knee Tumor Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Additional Red Flags: Acute Neck Pain Feature or risk factor Condition • Neurological symptoms in the limbs Neurological condition • Cerebrovascular symptoms or signs • Anticoagulant use Cerebral or spinal hemorrhage • Cardiovascular risk factors • Transient ischemic attack Vertebral or carotid aneurysm Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-Based Management of Acute Musculoskeletal Pain. A Guide for Clinicians. Australian Academic Press Pty. Lts; Bowen Hills, QLD: 2004.

Summary

Assessment and Diagnosis of Acute Pain: Summary • Comprehensive assessment and pain history is important in patients presenting with acute pain • Clinicians should be keep high degree of awareness for “red flags” indicating potential serious disorders • Although examination techniques lack specificity for diagnosing causes of musculoskeletal pain, physical examination may assist the identification of serious conditions underlying pain • Imaging is indicated mainly when a serious condition is suspected